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Objective:
To design, implement, and determine the efficacy of a suite of interventions for reducing postoperative pulmonary complications.
Design:
A before-after trial, in which we compared our National Surgical Quality Improvement Program (NSQIP) risk-adjusted pulmonary outcomes before and after implementing a multidisciplinary pulmonary care program, known as “ICOUGH”.
Setting:
An urban, academic, safety net hospital.
Patients:
All patients who underwent general or vascular surgery at our institution in a one-year period before or after implementation of ICOUGH.
Interventions:
A multidisciplinary team developed a strategy to reduce pulmonary complications, based upon comprehensive patient education and a set of standardized electronic physician orders to specify early postoperative mobilization and pulmonary care. Designated by the acronym ICOUGH, the program emphasizes Incentive spirometry, Coughing/deep breathing, Oral care (tooth-brushing and mouthwash twice daily), Understanding (patient/family education), Getting out of bed at least three times daily, and Head of bed elevation. Nursing and physician education promoted a culture of mobilization and ICOUGH interventions. ICOUGH was implemented for all general and vascular surgery patients at our institution in August 2010.
Main Outcome Measures:
NSQIP reported incidence of postoperative pneumonia and unplanned intubation, which NSQIP reports as observed/expected ratios (O/E) for the one-year period before implementing ICOUGH, and as odds ratios (OR, statistically comparable to O/E) for the period after its implementation.
Results:
Before the implementation of ICOUGH, our O/E for pneumonia was 2.13, falling to an OR of 1.58 after its implementation. Unplanned intubations fell from 2.10 before ICOUGH to 1.31 after ICOUGH.
Conclusions:
ICOUGH, a standardized postoperative care program emphasizing patient education, early mobilization, and pulmonary interventions, effectively reduced the risk-adjusted incidence of postoperative pneumonia and unplanned intubation among our patients.